Pharmacodynamic Processes

Examine Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
•    Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
•    Which decision did you select?
•    Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
•    Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
•    Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
•    Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
•    Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
•    Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
•    Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

CASE STUDY:
BACKGROUND
Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.
The parents give you a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.
Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.
SUBJECTIVE
Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.

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MENTAL STATUS EXAM
The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.
Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation
RESOURCES
§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners’ Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.

MY DECISION:
decision Point One
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
Decision Point Two
Change to Ritalin LA 20 mg orally daily in the MORNING
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, and the switch to the LA preparation is lasting Katie throughout the school day
Katie’s reports of her heart feeling “funny” have gone away. Pulse was 92 during today’s office visit
Decision Point Three
Maintain current dose of Ritalin LA and reevaluate in 4 weeks
Guidance to Student
At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.
OTHER OPTIONS:(1)
Decision Point One
Begin Wellbutrin (bupropion) XL 150 mg orally daily
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents inform you that they stopped giving Katie the medication because about 2 weeks into the prescription, Katie told her parents that she was thinking about hurting herself. This scared the parents, but they didn’t want to “bother you” by calling the office, so they felt that it would be best to just stop the medication as they would be seeing you in two weeks
Decision Point Two
Discontinue Wellbutrin and begin Strattera (atomoxetine) 10 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are getting a bit better
They are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three
Discontinue Strattera and begin Intuniv extended release, 1 mg orally daily
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it. Keep in mind that if you decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
OPTION 2:
Decision Point One
Begin Intuniv extended release 1 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s teacher reports no change in her classroom behaviors
Katie’s parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”
Decision Point Two
Discontinue Intuniv and begin Dexedrine (dextroamphetamine) 5 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are better, but that she can be a bit “hyper” at times. Katie’s parents report that Katie is sometimes too “wound up” to go to bed and bedtime has become a “difficult” time in the house
Katie’s parents are also concerned about her appetite, which has decreased since beginning the Dexedrine. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three

Discontinue Dexedrine and begin Concerta (methylphenidate) 18 mg orally daily
Guidance to Student
Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. You should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily. Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.

Examine Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
•    Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
•    Which decision did you select?
•    Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
•    Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
•    Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
•    Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
•    Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
•    What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
•    Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
•    Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

CASE STUDY:
BACKGROUND
Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.
The parents give you a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.
Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.
SUBJECTIVE
Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.

MENTAL STATUS EXAM
The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.
Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation
RESOURCES
§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners’ Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.

MY DECISION:
decision Point One
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
Decision Point Two
Change to Ritalin LA 20 mg orally daily in the MORNING
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, and the switch to the LA preparation is lasting Katie throughout the school day
Katie’s reports of her heart feeling “funny” have gone away. Pulse was 92 during today’s office visit
Decision Point Three
Maintain current dose of Ritalin LA and reevaluate in 4 weeks
Guidance to Student
At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.
OTHER OPTIONS:(1)
Decision Point One
Begin Wellbutrin (bupropion) XL 150 mg orally daily
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents inform you that they stopped giving Katie the medication because about 2 weeks into the prescription, Katie told her parents that she was thinking about hurting herself. This scared the parents, but they didn’t want to “bother you” by calling the office, so they felt that it would be best to just stop the medication as they would be seeing you in two weeks
Decision Point Two
Discontinue Wellbutrin and begin Strattera (atomoxetine) 10 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are getting a bit better
They are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three
Discontinue Strattera and begin Intuniv extended release, 1 mg orally daily
Guidance to Student
Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.
After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it. Keep in mind that if you decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.
The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.
OPTION 2:
Decision Point One
Begin Intuniv extended release 1 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s teacher reports no change in her classroom behaviors
Katie’s parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”
Decision Point Two
Discontinue Intuniv and begin Dexedrine (dextroamphetamine) 5 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are better, but that she can be a bit “hyper” at times. Katie’s parents report that Katie is sometimes too “wound up” to go to bed and bedtime has become a “difficult” time in the house
Katie’s parents are also concerned about her appetite, which has decreased since beginning the Dexedrine. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three

Discontinue Dexedrine and begin Concerta (methylphenidate) 18 mg orally daily
Guidance to Student
Dexedrine can cause agitation and overstimulation, which may explain Katie’s being “hyper” behaviors in the classroom. You should assess the time of day that parents administer the medication as long-acting stimulants should be given in the morning as opposed to afternoon as afternoon administration could impact sleep. Normal side effects of Dexedrine use include decreased appetite. If Katie is experiencing these side effects with just 5 mg daily, it would be expected that side effects may worsen at 10 mg daily. Concerta may be an appropriate choice, as other stimulant classes should be tried before moving to second-line treatments (such as Strattera). If Katie demonstrates similar side effects to Concerta, then a second-line agent may be considered.

For more information on Pharmacodynamic Processes read this:https://en.wikipedia.org/wiki/Pharmacodynamics

Pharmacodynamic Processes

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